‘Very hit and miss’: an interpretive phenomenological analysis of ambulance service care for young people experiencing mental health crisis

Introduction: The ambulance service provides vital front line mental healthcare for young people in crisis, but there is a lack of evidence to guide best practice in this area. The lived experiences of service users can offer important insights to guide service development, therefore we carried out a qualitative evaluation of care provided by the ambulance service to young people experiencing a mental health-related emergency. Methods: Ten participants aged 16–25 years who had used the ambulance service due to a mental health crisis within the past 2 years were interviewed about their experiences and view of the care they received. Interviews were transcribed verbatim and interpretative phenomenological analysis used to explore participants’ individual narratives and identify recurrent themes. Results: A theme of inconsistent quality of care was evident in all participants’ accounts. Contributing to this superordinate theme were six recurrent themes: positive qualities of individual ambulance clinicians, ambivalence about seeking care, the importance of retaining agency, need for mental health training for ambulance clinicians, need for inter-service collaboration and favourable comparison of the ambulance service to other services. Conclusions: We identified some examples of good practice, including person-centred care, respect for patient autonomy and attending to physical health needs. However, our findings suggest the quality of ambulance service mental healthcare is not yet sufficiently consistent. In the absence of mandatory high-quality mental health training and evidence-based protocols, the quality of care appears largely dependent on the qualities and experience of individual ambulance clinicians.


Introduction
Mental health presentations account for a significant and increasing share of the growing demand for emergency healthcare (Andrew et al., 2020;Duncan et al., 2019;Roggenkamp et al., 2018). However, the quality of care for those experiencing a mental health crisis has been recognised as highly variable and lacking parity with physical healthcare (Care Quality Commission, 2015;Crisp et al., 2016;Paton et al., 2016). A scoping review of the international literature on pre-hospital management of mental health-related emergencies  identified several barriers to the provision of high-quality care, including lack of training, limited treatment options and ineffective relationships with specialist mental health services.
The mental health of young people is of particular concern amid evidence of increasing prevalence of mental health conditions among under 25s (Erskine et al., 2015;Ford, 2020;Griffin et al., 2018;Patel et al., 2007). Mental health services have struggled to keep up with demand, resulting in high levels of unmet need (Children and Young People's Mental Health and Wellbeing Taskforce, 2015;Sheppard et al., 2018). In the absence of timely support, young people often do not access support until reaching crisis point (Gill et al., 2017;Owens et al., 2016). Therefore, while published data are limited, we would anticipate that a significant proportion of those using the ambulance service in mental health crises would be young people. Given their distinct developmental needs (Patel et al., 2007), there is a need to understand how services can provide effective mental health crisis care to this age group. This is supported by the NHS longterm plan (Department of Health and Social Care, 2019), which included a focus on improving mental health crisis support for young people.
The lived experiences of service users can offer important insights to guide service improvement; however, previous qualitative research on the provision of mental health crisis care has focused primarily on clinicians' perspectives. Therefore, we undertook a qualitative evaluation of the care provided by the ambulance service to young people in mental health crisis.

Conclusions:
We identified some examples of good practice, including person-centred care, respect for patient autonomy and attending to physical health needs. However, our findings suggest the quality of ambulance service mental healthcare is not yet sufficiently consistent. In the absence of mandatory high-quality mental health training and evidence-based protocols, the quality of care appears largely dependent on the qualities and experience of individual ambulance clinicians. Those who spoke about more than one episode of care (n = 9) described considerable variability in the quality of care on each occasion. For instance, when asked how her most recent experience compared to other occasions on which she had come into contact with the ambulance service, one participant responded: I'd say it's a 50/50 split, I'd say that was bang on average, I'd say about half of my other experiences were a lot more positive, but then the other half were like worse. ('Mia',19) Participants also spoke about variability in the skill levels of ambulance clinicians. Some were perceived as highly skilled in supporting young people experiencing a mental health crisis, while others were seen to lack the necessary knowledge, confidence and motivation. For instance, one participant commented:

Keywords
there was definitely some people that are quite, seem like they had good experience in mental health and then there was maybe a few examples where they clearly didn't understand it. ('Dylan',25) Another remarked: sometimes it's felt like, it's just a job, we'll take her 'cause it's just a job, whereas other times it's felt more like, genuinely we care. ('Beth',18) There was also a notable contrast between the largely positive appraisal of the physical healthcare provided and often more negative views of mental healthcare. One participant expressed that she felt the ambulance crew who attended would have 'just turned around and left' if it hadn't been for her physical health. She went on to suggest that she would be reluctant to contact the ambulance service for a mental health-related emergency in future: if obviously I had a physical issue then perfect … but if I was in that kind've situation again and I was attempting to take my life then, I think I would rather just stay at home and sleep it off. ('Grace',24) improvement. All interviews were audio-recorded. Mean interview duration was 31 minutes (range 19-51 minutes).

Data analysis
Interviews were transcribed verbatim by members of the analysis team. Following familiarisation, initial notes were added to the transcript noting linguistic, descriptive and conceptual points of interest. Emergent themes were then developed and refined through regular discussions between the analysis team comprising a post-doctoral research psychologist (BG), an assistant psychologist (HN), a young person with expertise by experience (SR) and a research paramedic (LP). Having completed this process for each transcript individually, recurrent themes across participants were identified and organised into a hierarchical structure.

Patient and public involvement
To facilitate meaningful co-production, a young person (SR) with lived experience of using the ambulance service in a mental health-related emergency co-wrote the interview schedule, designed the promotional leaflet for the study, was involved in interviewing, transcribing and data analysis and is a co-author of this manuscript.

Sample characteristics
Participant characteristics are presented in Table 1.

Summary of recurrent themes
While the analysis was primarily idiographic in focus, there was considerable overlap in the emergent themes. We identified a single superordinate theme of inconsistency in quality of care that was evident in all participants' accounts. Contributing to this were six recurrent themes (three with sub-themes), all of which were identified in at least seven participants' accounts (Table 2). All participants commented positively on the personal qualities or interpersonal skills of some ambulance clinicians, using adjectives such as 'kind', 'caring', 'supportive', 'nice', 'understanding', 'friendly' and 'respectful'. Several participants mentioned that they particularly valued individual clinicians who 'took the extra time' to speak with them and try to understand their experience. Authenticity was valued by participants. Taking the time to do things such as introduce themselves, explain what they were doing and why and share their own experiences was interpreted as indicative of the clinicians' genuine concern for their well-being. For one participant, the authentic concern of a paramedic helped to mitigate, to some extent, the negative impact of a comment she found insensitive: I remember one thing that was quite poignant from my experience of the ambulance service where there was a paramedic who kept telling me, it's a silly choice to overdose. Other participants recounted positive experiences of having their agency preserved: one time I asked the ambulance to stop and they did, they sort've, I remember that quite well and that just made me feel like I had more control in a situation where I didn't have a lot. ('Beth',18) Such instances were experienced as particularly meaningful by individuals who had previous experience of disempowering situations, such as restrictive interventions while in in-patient care.

Theme 4
'I think training is really important': need for mental health training Increased training was recommended to counter inconsistency in ambulance clinicians' level of understanding, skills and confidence.
Subtheme: 'they have good intentions, but it's a bit stereotypical': need for better understanding of mental health Participants recounted multiple episodes of apparently well-intentioned clinicians behaving in ways, or saying things, they found unhelpful or insensitive. This often appeared to be due to misconceptions about mental health. For instance, a participant who had self-harmed was told 'you're too pretty to hurt yourself', which she saw as reflecting a misinformed stereotype about why young women hurt themselves.
Another participant who recounted being told overdosing was a 'silly choice' commented: it would be good if people could be trained to understand that well, it's not really like much of a choice, when people feel really overwhelmed. ('Ellen',24) She emphasised the importance of understanding the contextual factors that might lead to self-harm.

Subtheme: 'the worst thing for me is … a professional who doesn't feel quite confident enough': need for interpersonal skills and confidence
Participants spoke about some ambulance clinicians demonstrating limited skills in supporting a young person experiencing a mental health crisis: [he was] really like hectic and frantic and it just made things like a lot scarier than it should've been. ('Jessica',19) The importance of strong interpersonal skills was also emphasised: obviously when dealing with mental health it's quite important to get them all nuanced in personal skills. ('Dylan',25) well I was kinda hoping that I wouldn't be there for them to help me. ('Alex',17) The expectation of conveyance to hospital was a source of ambivalence for some participants: when the ambulance did get called, I was really upset I was like I don't want to go to hospital, but I knew that I needed to. ('Jessica',19) Reasons for not wanting to be conveyed to hospital were varied. For some, this was linked to negative past experiences. For 'Jessica', her ambivalence seemed to relate to a fear of losing agency ('I don't want anyone to know; I just want to deal with myself').
Subtheme: 'it's just a mental health problem': fear of not being taken seriously A fear of not being taken seriously, or being viewed as an 'attention seeker', contributed to ambivalence about seeking care for many participants. For some, this fear seemed to be linked to the perception that the ambulance service is only for physical health emergencies: ('Mia',19) Paradoxically, some reported they would not seek care from the ambulance service unless they were 'bad enough', but that at this stage they would struggle to engage with the support offered: by the time I'd want to hurt myself or kill myself then I wouldn't want their support anyway. ('Mia',19) Another participant commented:

I wouldn't wanna call if I hadn't hurt myself or like tried to kill myself, 'cause then I'd feel like an attention seeker.
if it wasn't bad enough that someone else would have to call them, then I wouldn't really wanna use their time. ('Paige',18) Theme 3 'Let me control the situation': the importance of retaining agency The importance of preserving choice and autonomy in a potentially disempowering situation was evident in most participants' accounts. For some, this theme was associated with a lack of agency: they weren't asking me if they could like what's it, do the, the necessary obs [observations], they just pulled me about. ('Freya',19) For one participant, a perceived lack of agency when being attended to by a male paramedic was particularly distressing due to prior negative experiences involving men: I like struggle with men and stuff and I was left with this random man … he was just pulling the covers away from me and stuff and I just freaked out even more. (Jessica,19) British Paramedic Journal 7(1) Subtheme: 'just kind've keep everyone in the loop': need for better communication Participants emphasised the importance of good communication to ensure effective care transitions and access to ongoing support. Several spoke about the importance of ensuring a 'proper handover' to hospital staff and goodquality medical notes and written communication: even when we got to the hospital they were talking to me obviously while they like booked me in, and they explained to me that it was quite busy and there was going to be a wait, but if I needed, they told me like where to go if I needed to talk to a doctor or if things started to get worse. ('Jessica',19) Conversely, another participant conveyed her perception of having been abandoned by the ambulance crew following a poor handover, saying 'they just dumped me in A&E'.

Theme 6
'I actually want more services to be like them': favourable comparison with other services While participants' accounts revealed areas for improvement, the ambulance service was compared favourably to other services, including acute hospitals, mental health services and the police. Interestingly, the non-specialist training of ambulance clinicians was perceived by some as facilitating a more person-centred approach: I actually find it very helpful that paramedics are not psychiatrists … I find that they don't tend to pathologise you so much … because they don't have the psychiatric terminology, and I would prefer more services to just treat you as you are, as another person, rather than as a patient with a particular label. ('Ellen',24) Discussion This qualitative evaluation of young people's experiences of ambulance service care in a mental health-related emergency suggests considerable inconsistency in care quality. While many participants described some positive experiences, this good practice appeared largely contingent on the personal qualities and experience of individual clinicians. While some ambulance clinicians were described as friendly, caring and respectful, others were experienced as insensitive or dismissive. Participants valued being listened to and offered choices in relation to their care, but some described disempowering experiences.
All participants perceived a need for mental health training for ambulance clinicians. This triangulates findings of a study of ambulance clinicians' experiences of working with people who have self-harmed (Jenkins, 2017). Participating clinicians acknowledged feeling unprepared to Another participant suggested that ambulance clinicians should complete placements within mental health services.
Subtheme: 'they just dressed my wounds and left': prioritising physical over mental health Some participants felt that their mental health was overlooked in favour of addressing their physical health needs: they don't acknowledge the mental health aspect, just try and do the physical, 'cause that's what they're comfortable with. ('Mia',19) Training was suggested to address this delivery gap between physical and mental healthcare. However, this experience was not universal: I think one thing that stood out for me was although they did, the paramedics dealt really efficiently with sort've like the physical problem, my mental health was never dismissed or sort've like forgotten. ('Beth',18) Where participants did report feeling that their mental health was given equal attention to their physical health, they interpreted this as individual clinicians going above and beyond as opposed to something to be expected.

Theme 5
'They just need to be more linked up': need for inter-service collaboration Subtheme: 'I don't feel like they're very closely tied in with other services': lack of joined-up working Participants' accounts illustrate how a lack of joint working between the ambulance service and partner organisations can result in poor patient experience: there was a lot of miscommunication between the ambulance crew and the police … I should've been admitted to the hospital, um and the police couldn't go anywhere because of my risk and everything, and the hospital didn't want to take me because they know my history, so they were like no we don't want her … so it was just 2 or 3 hours of going backwards and forwards. ('Freya',19) The use of the phrase 'we don't want her' suggests that the meaning of this incident for Freya was that she was being personally rejected, as opposed to services working together to determine the service best placed to meet her needs.
Participants also suggested that, for those not conveyed to hospital, the ambulance service should refer young people directly to relevant mental health services to limit delays in access to specialist care.

Conclusion
Young people experience the quality of mental healthcare provided by the ambulance service as highly variable. There is a need to improve the consistency of care provided through enhanced training, joined-up services and evidence-based protocols, while preserving the existing strengths of many ambulance clinicians in supporting young people in a person-centred manner.
manage the growing rate of mental health-related calls, with 'I'm not sure what I'm doing' and 'I worry about getting it wrong' emerging as key themes. Training needs identified in this evaluation included understanding of mental health conditions and the factors that might lead to crisis, interpersonal skills and the need for parity of mental and physical healthcare. A recent study of student paramedics (Credland et al., 2020) provides support for a suggestion by one participant that ambulance clinicians would benefit from completing placements within mental health services.
Fear of being viewed as a 'time-waster' was central to many participants' ambivalence about receiving care. Echoing the findings of an Australian study (Ferguson et al., 2019), this fear was underpinned by the belief that mental health crisis is not a legitimate reason to seek ambulance care. This belief was sometimes reinforced by ambulance clinicians addressing only the participants' physical health needs, reflecting previous research showing that paramedics often view mental health as a secondary consideration outside of their core role (Roberts & Henderson, 2009).
While participants described some instances of effective joint working between the ambulance service and partner organisations, there were also accounts of poor collaboration. The language of rejection and abandonment used by participants to describe these experiences demonstrates the potentially profound impact of such experiences. The need for improved care pathways for those in mental health crisis has recently been highlighted (White, 2021) and is a national policy priority (Department of Health and Social Care, 2019). Pilot programmes (East of England Ambulance Service NHS Trust, 2021; NHS England, n.d.; O'Hara et al., 2016) offer promising models for improved joint working.
Despite identifying areas for improvement, most participants compared the ambulance service favourably to other services. Participants valued the authenticity of ambulance clinicians and suggested that their non-specialist training may facilitate a more person-centred approach. Therefore, while seeking to increase the consistency of the care, it will be important to preserve the existing strengths of ambulance clinicians.

Limitations
The service evaluation was conducted in a region of the United Kingdom served by a single ambulance trust, which may limit the transferability of our findings. Further, while we advertised the evaluation widely, the sample was self-selecting, and most participants identified as female and White British. Additionally, we initially intended to conduct interviews in person, but due to COVID-19 restrictions most were conducted via telephone. While data from telephone interviews have been found to be largely comparable to face-to-face interviews (Sturges & Hanrahan, 2004), this may have impacted data richness.